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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> p 445 N SAN JOAQUIN, PHONE (209)468-3420 �� a►� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> f PERMIT F IRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made.to San Joaquin County for a permit toconstruct and/or install the work herein described. This <br /> application is-made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. [� <br /> Job Address City_ Lot Size/Acreage i <br /> Owner's Name . Q7/P�071_/ <br /> AddressPhone <br /> Contractor Sdress f- d License No� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 0 Out of Service Well ❑ �, r <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER C Monitorsnn�� Well ❑� <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES ��_ DI PO LD. �"^ PROP. LINE _1j92.!FOUNDATION --��f�„" 'AGRICULTURE WELL 'S 77 EI� LLs� 247PITS/SUMPS ZSPoP <br /> INTENDED USE -,TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIO <br /> f <br /> ❑ Industrial ❑ OpemBottom ❑ Manteca Dia. of(Nell Excavation Dia. of Well Casing l <br /> DomesticlPrivateravel Pack ' ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public <br /> fi I i Ot er _ %`Delta Depth of Groui Seal Type of Grout <br /> I ! Irrigation '*-prox.-Depth-+,,l_I Eastern -Surface Seal Installed by <br /> epeir Work Done U T of Pum "State'Work Done , <br /> Well Destruction , I Well Diameter �- �°'Sealing`Material A Deptih_ <br /> r .. ^-.. <br /> Depth. ller Material & DepthsQD <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11-REPAIR/ADDITION f-Jt,DESTRUCT-ION I (No septic system permilted'if-public sewer is []J <br /> � _ ' w <br /> Installation will serve: Residence��1 Commercial•,__._ Other - available within 200 feet.) <br /> a.bed4yd. A E �4 �T <br /> rooms 4 <br /> Character of soil se•a depth of 3 feet: <br /> Number of living units: Number of <br /> ` Water tale-depth - ° <br /> SEPTIC TANK. ,.O ;`Type/Mfg __ L� ...Capacity P, -No. Cornpartrr�ients ` ^� 'f F <br /> PKG, TREATMENT PLT.,❑ r rof <br /> Method-ofDisposal.' .� t <br /> -�� Distance to nearest; Well t Foundation propertyL e- � 1 <br /> LEACHING LINE Cl No. & Length of lines To tal1e gth/size t. � <br /> FILTER BED ❑ Distance to nearest:i Well Foundation property Line <br /> SEEPAGE PITS I I Depth <br /> Size d - <br /> Number -- <br /> SUMPS LI Distance to nearest: Well Fbundadon <br /> DISPOSAL PONDS CIr Property Line l .k <br /> ! hereby certify that I have prepared this application and=that_the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the followin <br /> em to an g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ploy y person in such manner-as.1.0 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws of California." # •..,�. p Y Persons subject to workman's compensa- <br /> The applicant31 ra requi ons. Complete drawing o evarse <br /> Signed X ' <br /> Title: or . <br /> Dater�. •�- � . <br /> FOR DEPARTMENT USE ONL '� <br /> Application Accepted by <br /> Data . Area <br /> Pit or G�t Inspection by/ atec� Fina nspection byOrr <br /> L gate <br /> Additional Comments: � <br /> Applicant - Return all copies to: San oaquin County Public Health Services <br /> fEnvironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> 1NF0 CASH DATE PERMIT'NO. <br /> 39Z <br /> EN t�•14.2 [REV.IinSl oo , 0 a <br /> Zai <br /> EH 2a <br />